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Chain of Custody and Analytical Re quest nRecorde side. Page 1 of 1 <br />PLEASE PRINT; provide as much information as possible. Refer to corresping <br />-D <br />CD <br />CD <br />J <br />0 <br />co <br />Company Name: Cotter Corporation <br />Tracking No. 3692013_00179971 <br />Report Mail Address: <br />Cotter Corporation - Canon City Mill <br />PO Box 1750; Canon City, CO 81215-1750 <br />Invoice Address: <br />PO Box 1750 <br />Canon City, CO 81215-1750 <br />Report Required For: POTWMtWTP ? <br />Other <br />Special Report Formats - ELI must be notified <br />prior to sample submittal for the following: <br />NELAC ? A21-A ? Level IV ? <br />Other <br />EDD/EDT ? Format <br />SAMPLE <br />IDENTIFICATION <br />(Name, Location, <br />Collection Collection <br />Date Time <br />' DIS-001A <br />2 <br />3 <br />S <br />6 <br />7 <br />I 8?n <br />12/14110 <br />8 <br />,o Relingtyshed by: B_ob Tennant <br />Custody 17:30 <br />Record Relinquished by: <br />MUST be <br />Signed Sample Disposal: <br />Project Name: hwartzwaider Water Monitoring Program - utscnarae <br />DATE: _121014110 SSTF: S25511 ler Name if other than Contact: <br />Contact Name: Kristy Usnick <br />Voice: 1-719-275-7413 ext. 213 <br />Invoice Contact: Kristy Usnick <br />Tel: 1-719-275-7413 ext. 213 <br />Fax: 1-719-275-1669 <br />Samp <br />1-303-642-3893 Schwartzwalder <br />Bob Tennant 17119-371-3009 <br />Purchase Order #: ELI Quote #: <br />Notify ELI prior to <br />RUSH sample <br />gecei t Temp <br />b 'C <br />Co ler ID( <br />Custo y Se I <br />Yl <br />intact <br />Y/N <br />Signature <br />YIN <br />Match LAB ID <br />Y/N <br />submittal for <br />4 a additional charges <br />I and scheduling <br />> r Comments: <br />3 0 r ; S8A Schedule Code <br />'? < (0 'a Wpp ?? DIS TABLE #4 <br />:3 19 <br />i = Frequency: -5 <br />?I I J <br />MATRIX 0: ~ <br />Water ? ® ® ? ? ? ? ? ? ? ? ® 15 day turn around <br />? ? ? ? ? ? ? ? ? ? ? ? <br />? ? ? ? ? ? ? ? ? ? ? ? <br />? ? ? ? ? ? ? ? ? 0 ? ? <br />? ? ? ? ? ? ? ? ? ? ? ? <br />? ? ? ? ? ? ? ? ? ? ? ? <br />? ? ? ? ? ? ? ? ? ? ? ? <br />? ? ? ? ? ? ? ? ? ? ? 0 <br />? ? ? ? ? ? ? ? ? ? ? ? <br />? ? (3 ? ? ? ? ? ? ? ? ? <br />DatelTime: 12114!10 Shipped by: Receiv d y: DatelTime: -)-t <br />Shipped by: Received by: Date/Time: <br />Date/Time: LABORATORY USE ONLY <br />Return to Client 13 Lab Disposal ® Sam le T # of frac